Post-earthquake health-service support, Nepal.

PROBLEM: Seven months after the April 2015 Nepal earthquake, and as relief efforts were scaling down, health authorities faced ongoing challenges in health-service provision and disease surveillance reporting. APPROACH: In January 2016, the World Health Organization recruited and trained 12 Nepalese medical doctors to provide technical assistance to the health authorities in the most affected districts by the earthquake. These emergency support officers monitored the recovery of health services and reconstruction of health facilities, monitored stocks of essential medicines, facilitated disease surveillance reporting to the health ministry and assisted in outbreak investigations. LOCAL SETTING: In December 2015 the people most affected by the earthquake were still living in temporary shelters, provision of health services was limited and only five out of 14 earthquake-affected districts were reporting surveillance data to the health ministry. RELEVANT CHANGES: From mid-2016, health facilities were gradually able to provide the same level of services as in unaffected areas, including paediatric and adolescent services, follow-up of tuberculosis patients, management of respiratory infections and first aid. The number of districts reporting surveillance data to the health ministry increased to 13 out of 14. The proportion of health facilities reporting medicine stock-outs decreased over 2016. Verifying rumours of disease outbreaks with field-level evidence, and early detection and containment of outbreaks, allowed district health authorities to focus on recovery and reconstruction. LESSONS LEARNT: Local medical doctors with suitable experience and training can augment the disaster recovery efforts of health authorities and alleviate their burden of work in managing public health challenges during the recovery phase.

Humanitarian response to reproductive and sexual health needs in a disaster: the Nepal Earthquake 2015 case study.

This case study describes the health response provided by the Ministry of Health of Nepal with support from UN agencies and several other organisations, to the 1.4 million women and adolescent girls affected by the major earthquake that struck Nepal in April 2015. After a post-disaster needs assessment, the response was provided to cater for the identified sexual and reproductive health (RH) needs, following the guidance of the Minimum Initial Service Package for RH developed by the global Inter-Agency Working Group. We describe the initiatives implemented to resume RH services: the distribution of medical camp kits, the deployment of nurses with birth attendance skills, the organisation of outreach RH camps, the provision of emergency RH kits and midwifery kits to health facilities and the psychosocial counselling support provided to maternity health workers. We also describe how shelter and transition homes were established for pregnant and post-partum mothers and their newborns, the distribution of dignity kits, of motivational kits for affected women and girls and female community health volunteers. We report on the establishment of female-friendly spaces near health facilities to offer a multisectoral response to gender-based violence, the setting up of adolescent-friendly service corners in outreach RH camps, the development of a menstrual health and hygiene management programme and the linkages established between adolescent-friendly information corners of schools and adolescent-friendly service centres in health facilities. Finally, we outline the gaps, challenges and lessons learned and suggest recommendations for preparedness and response interventions for future disasters.

Assessment of Ebola virus disease preparedness in the WHO South-East Asia Region.

OBJECTIVE: To conduct assessments of Ebola virus disease preparedness in countries of the World Health Organization (WHO) South-East Asia Region. METHODS: Nine of 11 countries in the region agreed to be assessed. During February to November 2015 a joint team from WHO and ministries of health conducted 4-5 day missions to Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. We collected information through guided discussions with senior technical leaders and visits to hospitals, laboratories and airports. We assessed each country's Ebola virus disease preparedness on 41 tasks under nine key components adapted from the WHO Ebola preparedness checklist of January 2015. FINDINGS: Political commitment to Ebola preparedness was high in all countries. Planning was most advanced for components that had been previously planned or tested for influenza pandemics: multilevel and multisectoral coordination; multidisciplinary rapid response teams; public communication and social mobilization; drills in international airports; and training on personal protective equipment. Major vulnerabilities included inadequate risk assessment and risk communication; gaps in data management and analysis for event surveillance; and limited capacity in molecular diagnostic techniques. Many countries had limited planning for a surge of Ebola cases. Other tasks needing improvement included: advice to inbound travellers; adequate isolation rooms; appropriate infection control practices; triage systems in hospitals; laboratory diagnostic capacity; contact tracing; and danger pay to staff to ensure continuity of care. CONCLUSION: Joint assessment and feedback about the functionality of Ebola virus preparedness systems help countries strengthen their core capacities to meet the International Health Regulations.

Assessment of geographical accessibility to COVID-19 testing facilities in Nepal (2021).

Background: Ensuring equitable physical access to SARS-CoV-2 testing has proven to be crucial for controlling the COVID-19 epidemic, especially in countries like Nepal with its challenging terrain. During the second wave of the pandemic in May 2021, there was immense pressure to expand the laboratory network in Nepal to ensure calibration of epidemic response. The expansion led to an increase in the number of testing facilities from 69 laboratories in May 2021 to 89 laboratories by November 2021. We assessed the equity of physical access to COVID-19 testing facilities in Nepal during 2021. Furthermore, we investigated the potential of mathematical optimisation in improving accessibility to COVID-19 testing facilities. Methods: Based on up-to-date publicly available data sets and on the COVID-19-related daily reports published by Nepal's Ministry of Health and Population from May 1 to November 15, 2021, we measured the disparities in geographical accessibility to COVID-19 testing across Nepal at a resolution of 1 km2. In addition, we proposed an optimisation model to prescribe the best possible locations to set up testing laboratories maximizing access, and tested its potential impact in Nepal. Findings: The analysis identified vulnerable districts where, despite ramping up efforts, physical accessibility to testing facilities remains low under two modes of travel-walking and motorized driving. Both geographical accessibility and its equality were better under the motorised mode compared with the walking mode. If motorised transportation were available to everyone, the population coverage within 60 min of any testing facility (public and private) would be close to threefold the coverage for pedestrians within the same hour: 61.4% motorised against 22.2% pedestrian access within the hour, considering the whole population of Nepal. Very low accessibility was found in most areas except those with private test centres concentrated in the capital city of Kathmandu. The hypothetical use of mathematical optimisation to select 20 laboratories to add to the original 69 could have improved access from the observed 61.4% offered by the laboratories operating in November to 71.4%, if those 20 could be chosen optimally from all existing healthcare facilities in Nepal. In mountainous terrain, accessibility is very low and could not be improved, even considering all existing healthcare facilities as potential testing locations. Interpretation: The findings related to geographical accessibility to COVID-19 testing facilities should provide valuable information for health-related planning in Nepal, especially in emergencies where data might be limited and decisions time-sensitive. The potential use of publicly available data and mathematical optimisation could be considered in the future. Funding: WHO Special Programme for Research and Training in Tropical Diseases (TDR).

Mapping the international health regulations monitoring and evaluation framework: an expert consultation, triangulation crosswalk and quantitative analysis.

The International Health Regulations Monitoring and Evaluation Framework (IHRMEF) includes four components regularly conducted by States Parties to measure the current status of International Health Regulations (IHR) 2005 core capacities and provide recommendations for strengthening these capacities. However, the four components are conducted independently of one another and have no systematic referral to each other before, during or after each process, despite being largely conducted by the same team, country and support organisations. This analysis sets out to identify ways in which IHRMEF components could work more synergistically to effectively measure the status of IHR core capacities, taking into account the country's priority risks. We developed a methodology to allow these independent components to communicate with each other, including expert consultation, a qualitative crosswalk analysis and a country-level quantitative analysis. The demonstrated results act as a proof of concept and illustrate a methodology to provide benefits across all four components before, during and after implementation.

Prevalence of Extended-Spectrum Beta-Lactamase (ESBL)-Producing Escherichia coli in Humans, Food, and Environment in Kathmandu, Nepal: Findings From ESBL E. coli Tricycle Project.

The need to address antimicrobial resistance (AMR) through a One Health (OH) approach is now well recognized. There is, however, limited guidance on how AMR surveillance should be implemented across sectors to generate meaningful AMR and AMU data for decision-making. Using a sympatric approach to cross-sector sample collection, Nepal adopted the WHO extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli) Tricycle Project as a step toward OH surveillance for assessing the prevalence of ESBL-producing E. coli across human, veterinary, and environment sectors. This involved a three-stage approach: identification of human hotspots (Stage 1) and sample collection sites for poultry (Stage 2) and wastewater (Stage 3). A total of 53 blood cultures from patients with bloodstream infections (BSIs), 100 stool samples from healthy pregnant women, 220 poultry ceca from slaughterhouses and live markets, and 48 wastewater samples were processed for bacterial culture and analyzed for the presence of ESBL-producing E. coli. The prevalence of ESBL-producing E. coli among isolated E. coli was the highest in wastewater samples (91%) followed by human BSIs (49%), poultry (38.6%), and fecal carriage isolates from healthy pregnant females (15%). A statistically significant association was seen in the prevalence of multidrug resistance among ESBL producers (52%) and nonproducers (26%). ESBL-producing E. coli was detected in all wastewater samples tested except for the upstream river. The findings of the study showed a high prevalence of ESBL-producing E. coli in samples from all three sectors and provided baseline data based upon which strategies for the safe disposal of communal and hospital waste, integrated AMR surveillance, and control strategies could be planned and implemented.

Health Emergency Risk Management in World Health Organization - South-East Asia Region during 2014-2023: synthesis of experiences.

Health Emergency Risk Management (ERM) has become increasingly critical on the global stage, prompted by the escalating frequency and severity of natural disasters and disease outbreaks. This paper offers a comprehensive synthesis of the World Health Organization's (WHO) experiences in the South-East Asia Region during the period 2014-2023, shedding light on its efforts to manage health emergencies and enhance resilience. The South-East Asia Region's unique environmental and economic diversity exposes it to significant health risks, including emerging infectious diseases and their implications for development, particularly in low-income countries. Here we document the transition from reactive emergency responses to proactive preparedness, catalyzed by prioritizing ERM as one of the regional flagship priorities in 2014. Key components of this initiative included capacity-building, the establishment of the South-East Asia Regional Health Emergency Fund (SEARHEF), and the implementation of the International Health Regulations (IHR 2005). This synthesis highlights the region's achievements in event reporting, development of national actions plan, successful Early Warning, Alert, and Response System (EWARS) implementation, and improvements in core capacities under IHR (2005). It also underscores the challenges associated with cross-border data sharing and regional collaboration that could strengthen ERM and enhance readiness for effective synergistic response.

Seroprevalence of SARS-CoV-2 infection in the general population of Nepal during the first and second generalized waves of the COVID-19 pandemic-2020-2021.

Few seroprevalence studies have been conducted on coronavirus disease (COVID-19) in Nepal. Here, we aimed to estimate seroprevalence and assess risk factors for infection in the general population of Nepal by conducting two rounds of sampling. The first round was in October 2020, at the peak of the first generalized wave of COVID-19, and the second round in July-August 2021, following the peak of the wave caused by the delta variant of SARS-CoV-2. We used cross-sectional probability-to-size (PPS)-based multistage cluster sampling to estimate the seroprevalence in the general population of Nepal at the national and provincial levels. We tested for anti-SARS-CoV-2 total antibody using the WANTAI SARS-CoV-2 Ab ELISA kit. In Round 1, the overall national seroprevalence was 14.4%, with provincial estimates ranging from 5.3% in Sudurpaschim to 27.3% in Madhesh Province. In Round 2, the estimated national seroprevalence was 70.7%, with the highest in the Madhesh Province (84.8%) and the lowest in the Gandaki Province (62.9%). Seroprevalence was comparable between males and females (Round 1, 15.8% vs. 12.2% and Round 2, 72.3% vs. 68.7%). The seroprevalence in the ecozones-Terai, hills, and mountains-was 76.3%, 65.3%, and 60.5% in Round 2 and 17.7%, 11.7%, and 4.6% in Round 1, respectively. In Nepal, COVID-19 vaccination was introduced in January 2021. At the peak of the first generalized wave of COVID-19, most of the population of Nepal remained unexposed to SARS-CoV-2. Towards the end of the second generalized wave in April 2021, two thirds of the population was exposed.

Building back better? Taking stock of the post-earthquake mental health and psychosocial response in Nepal.

BACKGROUND: The World Health Organization's 'building back better' approach advocates capitalizing on the resources and political will elicited by disasters to strengthen national mental health systems. This study explores the contributions of the response to the 2015 earthquake in Nepal to sustainable mental health system reform. METHODS: We systematically reviewed grey literature on the mental health and psychosocial response to the earthquake obtained through online information-sharing platforms and response coordinators (168 documents) to extract data on response stakeholders and activities. More detailed data on activity outcomes were solicited from organizations identified as most active in the response. To triangulate and extend findings, we held a focus group discussion with key governmental and non-governmental stakeholders in mental health system development in Nepal (n = 10). Discussion content was recorded, transcribed, and subjected to thematic analysis. RESULTS: While detailed documentation of response activities was limited, available data combined with stakeholders' accounts suggest that the post-earthquake response accelerated progress towards national mental health system building in the areas of governance, financing, human resources, information and research, service delivery, and medications. Key achievements in the post-earthquake context include training of primary health care service providers in affected districts using mhGAP and training of new psychosocial workers; appointment of mental health focal points in the government and World Health Organization Country Office; the addition of new psychotropic drugs to the government's free drugs list; development of a community mental health care package and training curricula for different cadres of health workers; and the revision of mental health plans, policy, and financing mechanisms. Concerns remain that government ownership and financing will be insufficient to sustain services in affected districts and scale them up to non-affected districts. CONCLUSIONS: Building back better has been achieved to varying extents in different districts and at different levels of the mental health system. Non-governmental organizations and the World Health Organization Country Office must continue to support the government to ensure that recent advances maximally contribute to realising the vision of a national mental health care system in Nepal.

Suicide burden and prevention in Nepal: The need for a national strategy.

Suicide is a major cause of deaths worldwide and is a key public health concern in Nepal. Although routine national data are not collected in Nepal, the available evidence suggests that suicide rates are relatively high, notably for women. In addition, civil conflict and the 2015 earthquake have had significant contributory effects. A range of factors both facilitate suicide attempts and hinder those affected from seeking help, such as the ready availability of toxic pesticides and the widespread, although erroneous, belief that suicide is illegal. Various interventions have been undertaken at different levels in prevention and rehabilitation but a specific long-term national strategy for suicide prevention is lacking. Hence, to address this significant public health problem, a multisectoral platform of stakeholders needs to be established under government leadership, to design and implement innovative and country-contextualized policies and programmes. A bottom-up approach, with active and participatory community engagement from the start of the policy- and strategy-formulation stage, through to the design and implementation of interventions, could potentially build grass-roots public ownership, reduce stigma and ensure a scaleable and sustainable response.

Post-disaster mental health and psychosocial support: Experience from the 2015 Nepal earthquake.

On 25 April 2015, an earthquake of magnitude 7.8 struck Nepal, which, along with the subsequent aftershocks, killed 8897 people, injured 22 303 and left 2.8 million homeless. Previous efforts to provide services for mental health and psychological support (MHPSS) in humanitarian settings in Nepal have been largely considered inadequate and poorly coordinated. Immediately after the earthquake, the Government of Nepal declared a state of emergency and the health sector started to respond. The immediate response to the earthquake was coordinated following the Inter-Agency Standing Committee (IASC) cluster approach. One month after the disaster, integrated MHPSS subclusters were initiated to coordinate the activities of many national and international, governmental and nongovernmental, partners. These activities were largely conducted on an ad-hoc basis, owing to lack of focus on MHPSS in the health sector's contingency plan for emergencies. The mental health subcluster attempted to implement a mental health response according to World Health Organization and IASC guidelines. The MHPSS response highlighted many strengths and weaknesses of Nepal's mental health system. This provides an opportunity to "build back better" through reform of mental health services. A strategic response to the lessons of the 2015 earthquake will deliver both improved population mental health and increased preparedness for the future.

Community prevalence of antibodies to human immunodeficiency virus in rural and urban Vellore, Tamil Nadu.

BACKGROUND: Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are becoming increasingly common in India. Currently, antenatal prevalence is a surrogate marker for HIV prevalence in the community. The association between antenatal and community prevalence of HIV needs to be validated so that estimates can be verified or adjusted appropriately. METHODS: A probability proportional to size cluster survey was conducted in the Kaniyambadi block of Vellore district and in the urban wards of Vellore town to estimate the prevalence of antibodies to rubella from August 1999 to February 2000. All personal identifier data from the serum samples were removed to yield a collection for which only the age and sex were known. Estimation of antibodies to HIV in sera from individuals between 15 and 40 years of age, was carried out by one screening ELISA and the reactive sera were further subjected to a supplementary test. RESULTS: We tested 1512 serum samples from subjects residing in rural areas and 1358 samples from those residing in urban areas. The seropositivity among rural samples was 0.66% and among urban samples 1.4%. The prevalence was almost equal among men and women and the youngest infected individual was 15 years old. CONCLUSION: The prevalence of HIV during the period of study was similar to the national surveillance data for Tamil Nadu based on antenatal women. HIV prevalence differs in urban and rural Tamil Nadu, with urban areas having a higher burden of the disease.

Monitoring data quality in syndromic surveillance: learnings from a resource limited setting.

BACKGROUND: India is in the process of integrating all disease surveillance systems with the support of a World Bank funded program called the Integrated Disease Surveillance System. In this context the objective of the study was to evaluate the components of the Orissa Multi Disease Surveillance System. MATERIALS AND METHODS: Multistage sampling was carried out, starting with four districts, followed by sequentially sampling two blocks; and in each block, two sectors and two health sub-centers were selected, all based on the best and worst performances. Two study instruments were developed for data validation, for assessing the components of the surveillance and diagnostic algorithm. The Organizational Ethics Group reviewed and approved the study. RESULTS: In all 178 study subjects participated in the survey. The case definition of suspected meningitis in disease surveillance was found to be difficult, with only 29.94%, who could be correctly identified. Syndromic diagnosis following the diagnostic algorithm was difficult for suspected malaria (28.1%), 'unusual syndrome' (28.1%), and simple diarrhea (62%). Only 17% could correctly answer questions on follow-up cases, but only 50% prioritized diseases. Our study showed that 54% cross-checked the data before compilation. Many (22%) faltered on timeliness even during emergencies. The constraints identified were logistics (56%) and telecommunication (41%). The reason for participation in surveillance was job responsibility (34.83%). CONCLUSIONS: Most of the deficiencies arose from human errors when carrying out day-to-day processes of surveillance activities, hence, should be improved by retraining. Enhanced laboratory support and electronic transmission would improve data quality and timeliness. Validity of some of the case definitions need to be rechecked. Training Programs should focus on motivating the surveillance personnel.