Symptoms 6 months following SARS-CoV-2 infection in Nepali women

In Nepal, over 1 million individuals have tested positive for SARS-CoV-2. We sought to describe the frequency of nonrecovery from this infection at 6 months and associated symptoms. We conducted a retrospective cohort study of 6142 women who had positive and negative PCR tests for this infection 6 months previously at 3 institutions in Kathmandu. In telephone interviews women provided information on 22 symptoms and their intensities, health status and history, and functional status. Of 3732 women who had tested PCR positive, 630 (16.9%) reported that they were unrecovered. These 630 unrecovered women were distinguished statistically from the 3102 recovered women by more frequent histories of allergies, rheumatoid disease, BCG immunization, Covid vaccination, strep throat and recent URIs, and both weight gain and weight losses of more than 5 kg in the 6 months following testing, and stressful events in the preceding year. Fatigue, pain, difficulty remembering, shortness of breath, heat and cold intolerance and unrefreshing sleep were reported in 41.9% to 10.5% of these 630 unrecovered women. Six months after confirmed SARS-CoV-2 infection 16.9% of Nepali women have long-COVID manifested as an immune, metabolic, and hormonal systems disruptive and dysfunction syndrome.

A Consecutive Series Study of the Frequencies, Intensities, and Natural History of Symptoms Following COVID-19 Infection in Nepali Men

BACKGROUND

In Nepal, approximately one million individuals, two-thirds men, have tested positive for COVID-19. The recovery picture from this infection is undescribed.

METHODS

At one major testing institution in Kathmandu, we attempted to contact men three-four months following documentation of a positive PCR Covid test. If the men contacted consented and reported that they had not completely recovered from their Covid infection, we then sought their answers about the presence and intensities of 23 symptoms.

RESULTS

Of 2043 consecutive test-positive men, we successfully contacted 1254 men/or family members. 14 men had died before our calls, and two reported having cancer or tuberculosis, providing 1238 individuals. 318 (25.7%) reported that they were unrecovered and 311 of these men were successfully interviewed. At a median of 3.5 months from diagnosis, 216 (17.4%) men reported fatigue, 153 (12.4%) pain, 134 (10.8%) difficulty remembering, 133 (10.7%) reduced physical activity, 114 (9.2%) shortness of breath, and 114 (9.2%) poor sleep. By 6 and 9 months, 108 (8.7%) and 55 (4.4%) of men respectively were still unrecovered.

CONCLUSIONS

In this PCR Covid test-positive series of symptomatic men, recovery was significantly prolonged compared with other viral illnesses.

Leishmania donovani persistence and circulation causing cutaneous leishmaniasis in unusual-foci of Nepal

Cutaneous leishmaniasis cases have increased dramatically in recent years in Nepal. The study offers molecular identification of the Leishmania species using 40 patient's aspiration biopsy samples, targeting markers kinetoplast minicircle DNA (kDNA) and internal transcribed spacer-1 (ITS1). Among molecularly diagnosed 22 cutaneous leishmaniasis cases, L. donovani complex was identified in 13 instances and L. major in 9 cases. The ITS1 PCR was positive in 12 of the positive nested- kDNA PCR cases (12/22), confirming L. donovani complex in seven of the cases and L. major in five of the cases. In addition, the study conclude that concurrent occurrence of atypical cutaneous infections caused by L. donovani parasite in 59.1% of cases and typical cutaneous infections caused by L. major parasite in 40.9% of cases. A Phylogentic analaysis showed that the detected L. donovani species present null genetic distances from seven references of L. donovani, but slight differences between ITS1 sequences and not grouped into a significant monophyletic cluster.

Dengue virus infection during window period of consecutive outbreaks in Nepal and assessment of clinical parameters

Nepal is an endemic country for dengue infection with rolling of every 3 year's clear cyclic outbreaks with exponential growth since 2019 outbreak and the virus gearing towards the non-foci temperate hill regions. However, the information regarding circulating serotype and genotype is not frequent. This research discusses on the clinical features, diagnosis, epidemiology, circulating serotype and genotype among 61 dengue suspected cases from different hospitals of Nepal during the window period 2017-2018 between the two outbreaks of 2016 and 2019. E-gene sequences from PCR positive samples were subjected to phylogenetic analysis under time to most recent common ancestor tree using Markov Chain Monte Carlo (MCMC) and BEAST v2.5.1. Both evolution and genotypes were determined based on the phylogenetic tree. Serotyping by Real-time PCR and Nested PCR showed the co-circulation of all the 3 serotypes of dengue in the year 2017 and only DENV-2 in 2018. Genotype V for DENV-1 and Cosmopolitan Genotype IVa for DENV-2 were detected. The detected Genotype V of DENV-1 in Terai was found close to Indian genotype while Cosmopolitan IVa of DENV-2 found spreading to geographically safe hilly region (now gripped to 9 districts) was close to South-East Asia. The genetic drift of DENV-2 is probably due to climate change and rapid viral evolution which could be a representative model for high altitude shift of the infection. Further, the increased primary infection indicates dengue venturing to new populations. Platelets count together with Aspartate transaminase and Aalanine transaminase could serve as important clinical markers to support clinical diagnosis. The study will support future dengue virology and epidemiology in Nepal.

The impact of COVID-19 pandemic on rabies post-exposure prophylaxis services in Asia

Human rabies is a preventable disease through post-exposure prophylaxis (PEP) in rabies endemic countries where enzootic cycle of dog rabies occurs. The COVID‑19 pandemic has induced an unprecedented challenge for under-funded and already stretched health‑care systems particularly in low- and middle-income countries, which are unfortunately bearing a huge burden of human rabies. An analysis of hospital-based PEP data in India, Nepal, Sri Lanka, and Thailand, focus group discussion and key informant interview have been carried out to better understand the impact of Covid-19 pandemic in human rabies prophylaxis. It is necessary to better prepare for human rabies prophylaxis in future pandemics based on lesson learnt from current pandemic. The PEP should be categorized as an emergency medical service, and it should be part of the hospital medical emergency. Mass dog vaccination against rabies should be accelerated to reduce the risk of potential bite of roaming dogs and pet dogs in communities. It is a wise decision to invest in cost-effective preparedness, i.e., mass dog vaccination rather than costly response, i.e., human rabies prophylaxis.

Audit of Clinical Care Received by COVID-19 Patients Treated at a Tertiary Care Hospital of Nepal in 2021

Like the world over, Nepal was also hard hit by the second wave of COVID-19. We audited the clinical care provided to COVID-19 patients admitted from April to June 2021 in a tertiary care hospital of Nepal. This was a cohort study using routinely collected hospital data. There were 620 patients, and most (458, 74%) had severe illness. The majority (600, 97%) of the patients were eligible for admission as per national guidelines. Laboratory tests helping to predict the outcome of COVID-19, such as D-dimer and C-reactive protein, were missing in about 25% of patients. Nearly all (>95%) patients with severe disease received corticosteroids, anticoagulants and oxygen. The use of remdesivir was low (22%). About 70% of the patients received antibiotics. Hospital exit outcomes of most (>95%) patients with mild and moderate illness were favorable (alive and discharged). Among patients with severe illness, about 25% died and 4% were critically ill, needing further referral. This is the first study from Nepal to audit and document COVID-19 clinical care provision in a tertiary care hospital, thus filling the evidence gap in this area from resource-limited settings. Adherence to admission guidelines was excellent. Laboratory testing, access to essential drugs and data management needs to be improved.

Evaluation of prognostic markers in patients infected with SARS-CoV-2

Prognostic markers are the biomarkers used to measure the disease progression and patient outcome regardless of treatment in coronavirus disease 2019 (COVID-19). This study aimed to analyze laboratory parameters as prognostic markers for the early identification of disease severity. In this study, 165 patients attending Sukraraj Tropical and Infectious Disease Hospital with COVID-19 were enrolled and divided into severe and non-severe groups. The demographic data, underlying co-morbidities, and laboratory findings were analyzed and compared between severe and non-severe cases. The correlation between the disease criticality and laboratory parameters was analyzed. Cut-off values of parameters for severe patients were speculated through the receiver operating characteristics (ROC) curve, and regression analysis was performed to determine the risk factors. Patients with severe COVID-19 infection had significantly higher absolute neutrophil count, neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), ferritin, positive carbohydrate reactive protein (CRP), glucose, urea, creatinine, and aspartate aminotransferase, while lower absolute lymphocyte count, absolute eosinophil count (AEC), and red blood cell count in comparison to non-severe infection. ROC analysis gave a cut-off value (sensitivity, specificity) of age, AEC, NLR, PLR, and ferritin as 47.5 years (70.2, 64.7%), 335 cells/mm3 (74, 67%) 3.3 (68.4, 63.7%), 129 (77.2, 51%), and 241 ng/mL (74.0%, 65.0%) respectively. Risk factor analysis showed higher age, low AEC, high ferritin, and positive CRP as independent risk factors associated with severe COVID-19 infection. Hematological and inflammatory markers, including novel NLR and PLR, should be assessed to aid clinicians in the early identification of severe cases, prioritization of cases, and effective management to decrease the mortality of COVID-19 patients.

Multidrug-resistant bacteria with ESBL genes: a growing threat among people living with HIV/AIDS in Nepal

BACKGROUND

Bacterial opportunistic infections are common in people living with HIV/AIDS (PLHA). Besides HIV-TB co-infection, lower respiratory tract infections (LRTIs) due to multidrug-resistant (MDR) bacteria cause significant morbidity and mortality among PLHA. This study identified bacterial co-infection of the lower respiratory tract and detected plasmid-mediated bla_TEM and bla_CTX-M genes among Extended-Spectrum β-Lactamase (ESBL) producing isolates from sputum samples in PLHA.

METHODS

A total of 263 PLHA with LRTIs were enrolled in this study, out of which, 50 were smokers, 70 had previous pulmonary tuberculosis, and 21 had CD4 count < 200 cells/µl. Sputum samples collected from PLHA were processed with standard microbiological methods to identify the possible bacterial pathogens. The identified bacterial isolates were assessed for antibiotic susceptibility pattern using modified Kirby Bauer disk diffusion method following Clinical Laboratory Standard Institute (CLSI) guidelines. In addition, plasmid DNA was extracted from MDR and ESBL producers for screening of ESBL genes; bla_CTX-M and bla_TEM by conventional PCR method using specific primers.

RESULTS

Of 263 sputum samples, 67 (25.48%) showed bacterial growth. Among different bacterial pathogens, Klebsiella pneumoniae, (17; 25.37%) was the most predominant, followed by Haemophillus influenzae, (14; 20.90%) and Escherichia coli, (12; 17.91%). A higher infection rate (4/8; 50%) was observed among people aged 61-70 years, whereas no infection was observed below 20 years. About 30.0% (15/50) of smokers, 32.86% (23/70) cases with previous pulmonary tuberculosis, and 52.38% (11/21) with CD4 count < 200 cells/µl had bacterial LRTIs. Among 53 bacterial isolates excluding H. influenzae, 28 isolates were MDR and 23 were ESBL producers. All ESBL producers were sensitive to colistin and polymyxin B. Among ESBL producers, 47.83% (11/23) possessed bla_CTX-M, 8.6% (2/23) were positive for bla_TEM gene, and 43.48% (10/23) possessed both ESBL genes.

CONCLUSION

The increasing rate of MDR bacterial infections, mainly ESBL producers of LRTIs causes difficulty in disease management, leading to high morbidity and mortality of PLHA. Hence, it is crucial to know the antibiogram pattern of the isolates to recommend effective antimicrobial therapy to treat LRTIs in PLHA.

gyrA ser83 mutation among fluoroquinolone-resistant Salmonella enterica serovars from enteric fever patients in tertiary care hospital, Kathmandu

BACKGROUND

The management of enteric fever through antibiotics is difficult these days due to the emerging resistance of Salmonella to various antimicrobial agents. The development of antimicrobial resistance is associated with multiple factors including mutations in the specific genes. To know the current status of mutation-mediated fluoroquinolone-resistance among Salmonella enterica serovars; Typhi, Paratyphi A, B and C, this study was focused on detecting gyrA ser83 mutation by restriction digestion analysis of gyrA gene using HinfI endonuclease.

RESULTS

A total of 948 blood samples were processed for isolation of Salmonella spp. and 3.4% of them were found to be positive for Salmonella growth. Out of the 32 Salmonella isolates, 2.2% were S. Typhi and 1.2% were S. Paratyphi A. More interestingly, we observed less than 5% of isolates were resistant to first-line drugs including chloramphenicol, cotrimoxazole and ampicillin. More than 80% of isolates were resistant to fluoroquinolones accounting for 84.4% to levofloxacin followed by 87.5% to ofloxacin and 100% to ciprofloxacin by disc diffusion methods. However, the minimum inhibitory concentration method using agar dilution showed only 50% of isolates were resistant to ciprofloxacin. A total of 3.1% of isolates were multidrug-resistant. Similarly, 90.6% of the Salmonella isolates showed gyrA ser83 mutation with resistance to nalidixic acid.

CONCLUSIONS

The increased resistance to fluoroquinolones and nalidixic acid in Salmonella isolates in our study suggests the use of alternative drugs as empirical treatment. Rather, the treatment should focus on prescribing first-line antibiotics since we observed less than 5% of Salmonella isolates were resistant to these drugs.

Experiences of COVID-19 patients admitted in a government infectious disease hospital in Nepal and its implications for health system strengthening: A qualitative study

INTRODUCTION

The COVID-19 pandemic has affected the health systems in many ways. It has put unprecedented strain on health systems worldwide and exposed gaps in public health infrastructure. A health system comprises all institutions and resources working towards improving and maintaining health. Among the different aspects of health system strengthening, a patient's experiences and expectations play a crucial role in determining how well the health facilities function. This study aims to explore health system strengthening's implications based on experiences and feedback provided by COVID-19 patients admitted to a government tropical and infectious disease hospital in Nepal.

METHODS

In this qualitative study, we collected the voluntary handwritten feedback by the admitted COVID-19 patients to document the feedback and experiences from a book, maintained by the hospital. We performed thematic content analysis using the World Health Organization's six building blocks of health system as a theoretical framework which included service delivery, health workforce, information, leadership and governance, financing, and access to medicines.

RESULTS

Most patients in this study had positive experiences on service delivery and health workforce. Some also highlighted the gaps in infrastructure, cleanliness, and hygiene. Many suggested positive experiences on other dimensions of the health system such as financing, governance and leadership, and access to medicines reflected upon by the patients' thankfulness to the hospital and the government for the treatment they received. The responses also reflected the inter-connectedness between the different building blocks of health system.

CONCLUSION

This study approached a unique way to strengthen the health system by exploring patients' feedback, which suggested an overall positive impression on most building blocks of health system. However, it also highlighted certain gaps in infrastructure, cleanliness, and hygiene. It reinforces the hospital management and government's role to continue its efforts to strengthen the health system.

Antibiotic Susceptibility, Biofilm Production, and Detection of mecA Gene among Staphylococcus aureus Isolates from Different Clinical Specimens

The increasing incidence of methicillin-resistant and biofilm-forming S. aureus isolates in hospital settings is a gruesome concern today. The main objectives of this study were to determine the burden of S. aureus in clinical samples, assess their antibiotic susceptibility pattern and detect biofilm formation and mecA gene in them. A total of 1968 different clinical specimens were processed to isolate S. aureus following standard microbiological procedures. Antibiotic susceptibility test of the isolates was performed by Kirby–Bauer disc-diffusion method following CLSI guidelines. Biofilm was detected through tissue culture plate method. Methicillin-resistant S. aureus (MRSA) isolates were screened using cefoxitin (30 µg) discs and mecA gene was amplified by conventional polymerase chain reaction (PCR). Of 177 bacterial growth, the prevalence of S. aureus was 15.3% (n = 27). MRSA were 55.6% (15/27) and 44% (12/27) exhibited multidrug resistance (MDR). There was no significant association between methicillin resistance and MDR (p > 0.05). Both MRSA and MSSA were least sensitive to penicillin (100%, 75%) followed by erythromycin (86.6%, 66.6%). Most of the MRSA (93.4%) were susceptible to tetracycline. All S. aureus isolates were biofilm producers—19 (70%) were weak and only one (4%) was a strong biofilm producer. The strong biofilm-producing MSSA was resistant to most of the antibiotics except cefoxitin and clindamycin. None of the MSSA possessed mecA gene while 8 (53.3%) MRSA had it. More than half of S. aureus isolated were MRSA. High incidence of multidrug resistance along with capacity to form biofilm among clinical isolates of S.aureus is a matter of apprehension and prompt adoption of biosafety measures is suggested to curb their dissemination in the hospital environments.

Emergence of cutaneous leishmaniasis in Nepal

BACKGROUND

Cutaneous leishmaniasis (CL) is endemic in 70 countries worldwide. Nepal is considered non-endemic for CL and hence the control program is targeted to visceral leishmaniasis (VL) only. Here, we report the emergence of CL cases in different parts of Nepal.

METHODS

We analyzed the CL and VL cases reported to Epidemiology and Diseases Control Division (EDCD), Ministry of Health and Population, Nepal through District Health Information System 2 (DHIS-2) and Early Warning and Reporting System (EWRS) during the past 4 years (2016-2019). Any laboratory-confirmed case was included in the study. Demographic and clinical details of each patient were transcribed into Excel sheets, verified with the case report forms and analyzed.

RESULTS

VL has been reported in Nepal since 1980, but CL was reported very recently. From 2016 to 2019, 42 CL cases were reported from 26 different hospitals to EDCD which had been diagnosed on the basis of clinical presentation, and laboratory findings (demonstration of amastigotes in Giemsa-stained smears and rK39 test results). Majority of the patients (31.0%, 13/42) visited to the hospital within 1-6 months of onset of lesions. Facial region (38.1%, 16/42) was the common place where lesions were found ompared to other exposed parts of the body. CL was successfully treated with miltefosine for 28 days. The majority of CL patients did not have history of travel outside the endemic areas and there was no report of sandfly from these areas.

CONCLUSION

These evidences highlight that the Government of Nepal need to pay more efforts on CL and include it in differential diagnosis by clinicians, and plan for an active surveillance when the country is targeting leishmaniasis elimination by the year 2025 with the decreasing number of VL cases.

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.

SARS-CoV-2 and Orientia tsutsugamushi co-infection in a young teen, Nepal: Significant burden in limited-resource countries in Asia?

Scrub typhus is caused by Orientia tsutsugamushi, transmitted through bites of infected chiggers (larval mites). During the coronavirus disease 2019 (COVID-19) pandemic, reports of co-infections with endemic pathogens are increasing around the world. Disease with similar clinical presentation may mask other disease diagnosis and increase the morbidity and mortality of the patients. We report co-infection between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and O. tsutsugamushi in a patient in Nepal presenting with fever, headache, retro-orbital pain, generalized body ache, and knee joints pain with a history of dry cough and dyspnea at night. Since scrub typhus is prevalent and considerate as one of the public health consents in Asian countries and the possible overlapping clinical manifestation with other infections including COVID-19, a further investigation required to determine the burden of SARS-CoV-2 and O. tsutsugamushi co-infection in scrub typhus-endemic countries in Asia.

Persistent Symptoms in Post-COVID-19 Patients Attending Follow-Up OPD at Sukraraj Tropical and Infectious Disease Hospital (STIDH), Kathmandu, Nepal

The long-term effects of COVID-19 among survivors is a matter of concern. This research aimed to study persistent symptoms in post-COVID-19 patients attending a follow-up clinic at a tertiary care hospital in Nepal. All patients, presenting to the outpatient clinic during the study duration of six weeks, with history of positive reverse transcriptase- polymerase chain reaction for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) at least two weeks prior to presentation, were included. The duration of follow-up ranged from 15 till 150 days with the mean duration of 28 days after diagnosis of COVID-19. Of 118 patients, 43 (36.4%) had a history of mild COVID-19, 15 (12.8%) had moderate, and 60 (50.8%) had severe. At the time of presentation, 97 (82.2%) patients reported that they had at least one persistent/new symptom beyond two weeks from the diagnosis of COVID-19. Dyspnea, fatigue, chest heaviness, and cough were the commonest persistent complaints in 48 (40.7%), 39 (33.1%), 33 (28%), and 32 (27.1%) patients, respectively. The findings in our study highlight the need for extended monitoring of post-COVID-19 patients following discharge, in order to understand and mitigate long-term implications of the disease.

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.

Antimicrobial Susceptibility Pattern of Salmonella spp. Isolated from Enteric Fever Patients in Nepal

INTRODUCTION

Enteric fever, a systemic infection caused by Salmonella enterica Typhi and S. enterica Paratyphi is one of the most common infections in developing countries such as Nepal. Aside from irrational practices of antibiotic use, mutations in chromosomal genes encoding DNA gyrase and Topoisomerase IV and by plasmid mediated quinolone resistant (PMQR) genes are suggested mechanisms for the development of resistance to nalidixic acid and reduced susceptibility to ciprofloxacin. Regardless of high endemicity of enteric fever in Nepal, there is paucity of studies on prevalence and drug-resistance of the pathogen. Therefore, this study aimed to assess the antibiotic susceptibility pattern of Salmonella isolates and determine the minimum inhibitory concentration of ciprofloxacin.

METHODS

A total of 1298 blood samples were obtained from patients with suspected enteric fever, attending Sukraraj Tropical and Infectious Disease Hospital (STIDH) during March-August, 2019. Blood samples were inoculated immediately into BACTEC culture bottles and further processed for isolation and identification of Salmonella Typhi and S. Paratyphi. Axenic cultures of the isolates were further subjected to antimicrobial susceptibility testing (AST) by using the modified Kirby-Bauer disc diffusion method based on the guidelines by CLSI. The minimum inhibitory concentration (MIC) of ciprofloxacin was determined by agar-dilution method.

RESULTS

Out of 1298 blood cultures, 40 (3.1%) were positive for Salmonella spp. among which 29 (72.5%) isolates were S. Typhi and 11 (27.5%) isolates were S. Paratyphi A. In AST, 12.5% (5/40), 15% (6/40) and 20% (8/40) of the Salmonella isolates were susceptible to nalidixic acid, ofloxacin and levofloxacin, respectively, whereas none of the isolates were susceptible to ciprofloxacin. The MIC value for ciprofloxacin ranged from 0.06-16 µg/mL in which, respectively, 5% (2/40) and 52.5% (21/40) of the isolates were susceptible and resistant to ciprofloxacin. None of the isolates showed multidrug-resistance (MDR) in this study.

CONCLUSION

This study showed high prevalence of quinolone-resistant Salmonella spp., while there was marked re-emergence of susceptibilities to traditional first option drugs. Hence, conventional first-line-drugs and third-generation cephalosporins may find potential usage as the empirical drugs for enteric fever. Although our reporting was free of MDR strains, extensive surveillance, augmentation of diagnostic facilities and treatment protocol aided by AST report are recommended for addressing the escalating drug-resistance in the country.

Epidemiology of dengue virus infections in Nepal, 2006-2019

BACKGROUND

Dengue is one of the newest emerging diseases in Nepal with increasing burden and geographic spread over the years. The main objective of this study was to explore the epidemiological patterns of dengue since its first outbreak (2006) to 2019 in Nepal.

METHODS

This study is a retrospective analysis that covers the last 14 years (2006-2019) of reported dengue cases from Epidemiology Diseases Control Division (EDCD), Ministry of Health and Population, Government of Nepal. Reported cases were plotted over time and maps of reported case incidence were generated (from 2016 through 2019). An ecological analysis of environmental predictors of case incidence was conducted using negative binomial regression.

RESULTS

While endemic dengue has been reported in Nepal since 2006, the case load has increased over time and in 2019 a total of 17 992 dengue cases were reported from 68 districts (from all seven provinces). Compared to the case incidence in 2016, incidence was approximately five times higher in 2018 [incidence rate ratio (IRR): 4.8; 95% confidence interval (CI) 1.5-15.3] and over 140 times higher in 2019 (IRR: 141.6; 95% CI 45.8-438.4). A one standard deviation increase in elevation was associated with a 90% decrease in reported case incidence (IRR: 0.10; 95% CI 0.01-0.20). However, the association between elevation and reported cases varied across the years. In 2018 there was a cluster of cases reported from high elevation Kaski District of Gandaki Province. Our results suggest that dengue infections are increasing in magnitude and expanding out of the lowland areas to higher elevations over time.

CONCLUSIONS

There is a high risk of dengue outbreak in the lowland Terai region, with increasing spread towards the mid-mountains and beyond as seen over the last 14 years. Urgent measures are required to increase the availability of diagnostics and resources to mitigate future dengue epidemics.

Sensitivity and Specificity of Lateral Flow Antigen Test Kits for COVID-19 in Asymptomatic Population of Quarantine Centre of Province 3

Background Nearly after 6 months of the spread of Corona Virus Disease 19, along with the world Nepal is still trying to control the spread and prevent general population from acquiring it. With limited resources in manpower, technology and evidence it has been a difficult battle. But with time and more understanding of the virus new technology to detect the virus are coming up. It is a major breakthrough in the diagnostic field as this helps us in not only detecting the virus but also helps us to mobilize our human resources. This comes in a time where the cases are increasing at an alarming rate. Although numbers of Polymerase Chain Reaction testing have increased but due to the time consuming and the cost wise, we need a faster and equally reliable alternative. Antigen test approved by different countries can be used for point of care, screening and surveillance depending upon the requirements after calculating its sensitivity, specificity and accuracy. Objective To find out sensitivity and specificity of the Antigen test kit for COVID-19. Method Antigen tests were compared with Reverse Transcription Polymerase Chain Reaction as a reference standard in calculated sample size of 113 subjects in a high risk population. Both Reverse Transcription Polymerase Chain Reaction and antigen test were performed in a same subject with in maximum of 2 days' interval. Convenience sampling technique was used to select the subjects. Ethical approval was taken from Nepal Health Research Council before data collection. Study was done from August to September 2020 from Quarantine center of Province 3. Result There were total of 113 test carried out, among those 47 were positive and 66 were negative in Reverse Transcription Polymerase Chain Reaction. After preparing two by two table, Sensitivity and specificity of the tested was calculated which came out to be 85% and 100% respectively, with accuracy of 93.80%. Conclusion Even though the sensitivity and specificity came to be higher, this test should be interpreted cautiously depending upon the prevalence of Corona Virus Disease 19 in that particular community and the clinical and epidemiological context of the person who has been tested. When in doubt by clinical correlation should be confirmed with Reverse Transcription Polymerase Chain Reaction.

Bell's palsy as a possible neurological complication of COVID-19: A case report

COVID-19 has been associated with several neurological complications. We presented a case of Bell's palsy as a possible neurological complication of COVID-19 infection. Further research should be conducted to clarify the association, correlation, or causality between COVID-19 and neuroimmunological diseases.

Cutaneous Leishmaniasis of Lip and Role of Polymerase Chain Reaction: A Case Report

The diagnosis of cutaneous leishmaniasis is mostly confirmed by the identification of parasite in a skin smear or biopsy. However, this method may not always be sensitive enough to detect the disease when parasitic load is low. Molecular test such as polymerase chain reactions can be useful in such circumstances. Here, we report a case of cutaneous leishmaniasis diagnosed by a polymerase chain reaction test when both smear and biopsy failed to confirm the diagnosis. A 17-years-old female from mountainous district of Nepal, presented with a crusted plaque over the upper lip for a duration of 6 months. Both skin smear and biopsy from the lesion failed to demonstrate Leishmania parasite but a polymerase chain reaction test was positive for Leishmania donovani. This case emphasizes on the importance of molecular testing such as polymerase chain reaction when commonly performed diagnostics test fails to support confirmation of clinical diagnosis.

Molecular phylogeny and distribution of dengue virus serotypes circulating in Nepal in 2017

Dengue virus (DENV) infection is endemic in Nepal. Although infection rates are reported annually, little information is available about the circulating viral serotypes and genotypes. Here, we report the results of a multicentre cross-sectional study of DENV serotypes and genotypes sampled from individuals with suspected DENV infection in Nepal in 2017. Of the 50 patients sampled, 40 were serologically positive for DENV NS1, 29 for anti-DENV IgM, 21 for anti-DENV IgG and 14 were positive by qRT-PCR. The three serotypes DENV-1, 2 and 3 were detected and there was no DENV-4. Positive samples from serotyping were subjected to PCR amplification by envelope (E) gene specific primer and subsequent bidirectional sequencing of 5 samples. A time to most recent common ancestor phylogenetic tree was constructed from the new sequences obtained here together with historical DENV-1 and DENV-2 E gene sequences. The DENV-1 isolates (n = 2) from Nepalese individuals were closely related to Indian genotype V, whereas DENV-2 isolates (n = 3) belonged to Cosmopolitan genotype IVa, which is closely related to Indonesian isolates. Historical DENV isolates obtained between 2004 and 2013 clustered with Cosmopolitan IVb, Cosmopolitan IVa, and Asian II genotypes. All Nepalese isolates had different lineages with distinct ancestries. With the exception of isolates obtained in 2004, all other previously published isolates had ancestry to geographically distant part of the world. Molecular analysis revealed dengue epidemics to be comprised of different genotypes of serotype 1 and 2 raising concerns on potential role of different genotypes causing Dengue hemorrhagic fever. Also, our result indicated spread of DENV-2 in non-endemic area such as hilly region of Nepal which was considered to be free of dengue due to high altitude and cold weather.

Biofilm-Producing Candida Species Causing Oropharyngeal Candidiasis in HIV Patients Attending Sukraraj Tropical and Infectious Diseases Hospital in Kathmandu, Nepal

Introduction

Oropharyngeal candidiasis are the commonest fungal infections among HIV-positive patients. The main objective of this study was to explore biofilm-producing Candida species causing oropharyngeal infections among HIV patients attending Sukraraj Tropical and Infectious Diseases Hospital (STIDH) in Kathmandu, Nepal.

Methods

Oropharyngeal swabs were collected from the HIV-positive patients between July and December 2019. A total of 174 oropharyngeal swabs were cultured on Sabouraud Dextrose Agar (SDA). All samples were inoculated on SDA slants supplemented with chloramphenicol and underwent incubation at 37°C for 24-48 hours. Any visible growth reported was processed for the identification of the species. Candida species were differentiated based on the growth and colour of the isolates on CHROM agar candida. Biofilm production in Candida species was determined by the microtiter plate method (MPM). Antifungal susceptibility testing was performed using the disc diffusion method.

Results

Among 174 oropharyngeal samples, 23.6% (n=41/174) of them had oropharyngeal infections and 36.6% of the oropharyngeal infections (15/41) had CD4 T-lymphocytes count below 200 cells/mm³ who were also active tobacco users (p<0.05). Among Candidial growth, 61% (25/41) were Candida albicans and 39% (16/41) were non-albicans. Of 41 Candida spp., 65% (27/41) were biofilm producers. An equal proportion of Candida albicans (4 isolates) and non-albicans (4 isolates) were strong biofilm producers. C. albicans isolates were sensitive towards clotrimazole (96%; 24/25) and fluconazole (92%; 23/25), whereas sensitivity towards ketoconazole was only 48% (12/25). Non-albicans Candida was highly sensitive to amphotericin-B (62.5%; 10/16) followed by clotrimazole (56.2%; 9/16). The biofilm-producing Candida isolates showed the highest resistivity (51.9%; 14/27) to ketoconazole and lowest (22.2%; 6/27) to clotrimazole.

Conclusion

Oropharyngeal candidiasis is a common opportunistic infection among HIV-infected individuals. The majority of cases of oropharyngeal candidiasis are caused by biofilm producers Candida albicans and non-albicans Candida. Biofilm producers Candida were more resistant towards commonly used antifungal drugs.

Opportunistic Respiratory Infections in HIV Patients Attending Sukraraj Tropical and Infectious Diseases Hospital in Kathmandu, Nepal

Introduction

Opportunistic bacterial and fungal infections are the major cause of morbidity and mortality among immune suppressed HIV-positive patients. The main objective of this study was to determine bacterial and fungal organisms causing respiratory infections and their susceptibility to commonly prescribed antimicrobials among HIV patients attending a tertiary infectious disease hospital in Kathmandu.

Methods

Sputum samples were collected from the HIV-positive patients attending Sukraraj Tropical and Infectious Disease Hospital (STIDH) from August 2017 to March 2018. A total of 100 sputum samples were cultured on conventional bacterial and fungal culture media. Bacterial and fungal isolates were identified based on their colony characteristics, microscopic morphology and various biochemical tests. Antibiotic susceptibility test (AST) of bacterial isolates was performed by modified Kirby Bauer disc diffusion method.

Results

Out of 100 sputum samples cultured, 24% (n=24) showed bacterial growth, 42% (n=42) showed fungal growth and 10% (n=10) had both bacterial and fungal growth. Among bacteria, 91.6% (n=22) were monomicrobial and 8.4% (n=2) were polymicrobial in growth, of which, Klebsiella pneumoniae (37.5%) were predominant isolates, followed by Pseudomonas aeruginosa (29.2%), and Escherichia coli (16.7%). The antibiotic susceptibility test (AST) showed 68% (17/25) of bacterial isolates were multi-drug resistant (MDR) and among them 41.2% (7/17) were found to be extended spectrum β lactamase (ESBL) producers. Fungal growth was observed in 42% of samples (42/100). A total of six different species of Candida and four different genera of molds were identified. On species differentiation, Candida albicans (20%) were followed by Candida parapsilosis (4%), and Candida dubliniensis (3%); and various molds were Aspergillus fumigatus (4%), Aspergillus flavus (2%), and Penicillium species (5%). CD4 count was inversely associated with bacterial and fungal infections. Fifty percent of the patients with the fungal infections had a CD4 count below 200. No fungal organisms were isolated from HIV-positive patients under antifungal drug treatment.

Conclusion

HIV-positive patients with a CD4 count less than 200 cells/µL are more vulnerable to opportunistic infections of bacterial and fungal origin. Early isolation, identification and appropriate treatment can reduce mortality due to co-infections. Routine screening of opportunistic pathogens is critical to contain the disease progression.

A case of high altitude cutaneous leishmaniasis in a non-endemic region in Nepal

A case of cutaneous leishmaniasis was discovered in a 32-year old man with a persistent erythematous plaque. The patient resides in a high altitude (~2000 m above sea level) area that is not endemic for cutaneous leishmaniasis in the Dunai village of Dolpa, Nepal. The patient's lesion was initially misdiagnosed as lupus vulgaris. After response failure to initial treatment, additional testing by histological microscopy revealed the presence of Leishmania amastigotes in tissue from the lesion, and the diagnosis of cutaneous leishmaniasis was confirmed by nested PCR DNA assay of tissue from the lesion, and by a positive rK39 test in blood. Sequencing of the kinetoplast region confirmed the presence of Leishmania donovani complex. The patient responded well to treatments for cutaneous leishmaniasis and the skin lesions regressed after 6 months. This is the first known case of cutaneous leishmaniasis in a patient in Nepal who resides at high altitude in a non-endemic region. Increasing temperatures in this region of Nepal may be expanding the range of vectors that transmit cutaneous leishmaniasis.

Preference of the Redbanded Stink Bug (Hemiptera: Pentatomidae) for Selected Spring Host Plants

The redbanded stink bug, Piezodorus guildinii (Westwood), has emerged as a major stink bug pest of soybean in Louisiana during the last decade. In the spring, this species is usually found in leguminous hosts where populations can build up before migrating to soybean fields in the summer. However, studies looking at the preference of this species to the potential spring leguminous hosts under the natural conditions are lacking. Field studies were conducted in different geographical locations of Louisiana from 2013 to 2015 to evaluate preference of P. guildinii to six different leguminous cover crops: crimson clover, (Trifolium incarnatum L.), cardinal red clover, (Trifolium pratense L.), Austrian winter pea, (Pisum sativum L.), berseem clover, (Trifolium alexandrinum L.), hairy vetch, (Vicia villosa Roth), and white clover, (Trifolium repens L.). Our study showed that the odds of finding both adult and nymph P. guildinii was significantly higher in crimson clover followed by white clover, while the odds of finding both adult and nymph P. guildinii was significantly lower in other hosts. Therefore, crimson and white clovers are the preferred hosts as well as the important reproductive host plants of P. guildinii in the spring season.

Impact of a massive earthquake on adherence to antiretroviral therapy, mental health, and treatment failure among people living with HIV in Nepal

INTRODUCTION

The April 2015 Nepal earthquake resulted in more than 8,700 deaths and 22,000 casualties including damage to health facilities. The impact of this situation on chronic conditions such as human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) may become a long-lasting public health threat. Therefore, the objectives of this study were i) to assess the association of antiretroviral therapy (ART) adherence with mental health problems, and social behaviors, ii) to examine factors affecting treatment failure, and iii) to investigate changes in ART adherence and post-traumatic stress disorder (PTSD) among people living with HIV 6 and 12 months after the disaster.

METHODS

Study was conducted 6 months after the earthquake in 2015 with a sample size of 305 earthquake victims with HIV and followed after 12 months of the earthquake. A logistic regression analysis was used to examine relationships, while a paired t-test analysis was conducted to assess changes in adherence to ART and PTSD level at 6 months and 12 months after earthquake.

RESULTS

In the earthquake, 5.2% of the participants lost their family member. Approximately 44% of participants had earthquake-PTSD symptoms and 50% experienced HIV stigma. PTSD and HIV status disclosure were significantly associated with adherence to ART, while HIV stigma and religion were associated with treatment failure. PTSD and adherence levels to ART were significantly improved over the 6-month period.

CONCLUSION

Awareness programs for general public to eliminate HIV stigma; promote psychosocial counseling to earthquake victims living with HIV in order to reduce PTSD will contribute to maintaining optimal ART adherence and to prevent treatment failure.

Cold Tolerance and Supercooling Capacity of the Redbanded Stink Bug (Hemiptera: Pentatomidae)

The redbanded stink bug Piezodorus guildinii (Westwood) (Hemiptera: Pentatomidae) is an invasive stink bug species in the United States. First documented as a soybean pest in Louisiana in the year 2000, this species continues to spread in the Mid-South region of the United States. We designed laboratory and field studies to investigate supercooling points, lethal exposure time (LT), critical thermal minimum (CTmin), and winter mortality of this species. The mean supercooling points (SCP) ± SE of adult field collected P. guildinii ranged from -8.3 ± 0.2°C (highest) in March to -11.0 ± 0.2°C (lowest) in January. Significant differences in SCP occurred over the months and between sexes with significant interactions between month and sex. The CTmin was significantly different between adults and nymphs (third, fourth, and fifth instars combined). LT50 and LT90 were evaluated at subzero temperatures of 0°C, -2°C, and -5°C. There were significant differences in LT50 and LT90 among the temperature treatments. Winter survival significantly differed between the two study years and decreased with progression of winter months.

Genotypic Characterization of Human Immunodeficiency Virus Type 1 Derived from Antiretroviral Drug-Treated Individuals Residing in Earthquake-Affected Areas in Nepal

Molecular epidemiological data on human immunodeficiency virus type 1 (HIV-1) are limited in Nepal and have not been available in areas affected by the April 2015 earthquake. Therefore, we conducted a genotypic study on HIV-1 genes derived from individuals on antiretroviral therapy residing in 14 districts in Nepal highly affected by the earthquake. HIV-1 genomic fragments were amplified from 40 blood samples of HIV treatment-failure individuals, and a sequencing analysis was performed on these genes. In the 40 samples, 29 protease, 32 reverse transcriptase, 25 gag, and 21 env genes were sequenced. HIV-1 subtyping revealed that subtype C (84.2%, 32/38) was the major subtype prevalent in the region, while CRF01_AE (7.9%, 3/38) and other recombinant forms (7.9%, 3/38) were also detected. In addition, major drug resistance mutations were identified in 21.9% (7/32) of samples, indicating the possible emergence of HIV-1 drug resistance in earthquake-affected areas in Nepal.

Prevalence of intestinal parasitic infections among people living with HIV/AIDS visiting a central hospital of Kathmandu Nepal

Backgrounds: Intestinal Parasitic Infection (IPI) plays a vital role in the prognosis of People Living with HIV/AIDS (PLHA).Aims and Objectives: In this study, we aimed to measure the prevalence and associated factors of IPI among PLHA and non-HIV patients attending Sukraraj Tropical and Infectious Disease Hospital, Teku, Kathmandu.Materials and Methods: A cross-sectional study was conducted among 193 PLHA and 111 non-HIV patients having either of gastrointestinal disorders. Direct smear, Formalin ethyl acetate sedimentation and Kinyoun’s modified acid fast staining methods were applied to detect intestinal parasites from stool samples and CD4 T-cell counts of PLHA was recorded from ART centre of hospital.Results: The overall prevalence of IPI was found to be 16.12% (19.17% in PLHA and 10.81% in non-HIV subjects). Prevalence was higher in PLHA (p<0.06) in which poly parasitic infection was common (24%) with the protozoa predominating over helminths. CD4 T-cell counts <200/μl (p<0.06) and diarrhoea (p<0.06) were associated with increased IPI in PLHA. Cryptosporidium parvum was found in 19.05% cases of PLHA having CD4 T-cell counts <200/μl.Conclusions: The higher prevalence of opportunistic protozoa among PLHA indicates the need of routine parasitic investigation using sensitive methods so that it will be helpful for the proper therapeutic management.Asian Journal of Medical Sciences Vol.8(5) 2017 87-92

Intercrop movement of convergent lady beetle, Hippodamia convergens (Coleoptera: Coccinellidae), between adjacent cotton and alfalfa

A 2-year study was conducted to characterize the intercrop movement of convergent lady beetle, Hippodamia convergens Guerin-Meneville (Coleoptera: Coccinellidae) between adjacent cotton and alfalfa. A dual protein-marking method was used to assess the intercrop movement of the lady beetles in each crop. In turns field collected lady beetles in each crop were assayed by protein specific ELISA to quantify the movement of beetles between the crops. Results indicated that a high percentage of convergent lady beetles caught in cotton (46% in 2008; 56% in 2009) and alfalfa (46% in 2008; 71% in 2009) contained a protein mark, thus indicating that convergent lady beetle movement was largely bidirectional between the adjacent crops. Although at a much lower proportion, lady beetles also showed unidirectional movement from cotton to alfalfa (5% in 2008 and 6% in 2009) and from alfalfa to cotton (9% in 2008 and 14% in 2009). The season-long bidirectional movement exhibited by the beetles was significantly higher in alfalfa than cotton during both years of the study. The total influx of lady beetles (bidirectional and unidirectional combined) was significantly higher in alfalfa compared with that in cotton for both years. While convergent lady beetles moved between adjacent cotton and alfalfa, they were more attracted to alfalfa when cotton was not flowering and/or when alfalfa offered more opportunities for prey. This study offers much needed information on intercrop movement of the convergent lady beetle that should facilitate integrated pest management decisions in cotton utilizing conservation biological control.

First report of Chikungunya virus infection in Nepal

Chikungunya virus is an emerging arboviral disease that has been spreading rapidly across south Asia in recent years. Until recently, no chikungunya cases have been reported in Nepal. For the first time, we report three cases of chikungunya virus infection in Nepal