An outbreak investigation of scrub typhus in Nepal: confirmation of local transmission.

BACKGROUND: Scrub typhus is a largely ignored tropical disease and a leading cause of undifferentiated febrile illness in the areas of tsutsugamushi triangle caused by Orientia tsutsugamushi. It is frequently diagnosed in South Asian countries, although clear epidemiological information is not available from Nepal. After the 2015 earthquake in Nepal, a sudden upsurge in scrub typhus cases was reported. The objective of this study was to investigate epidemiology of scrub typhus and its causative agents in humans, animals, and chigger mites to understand the ongoing transmission ecology. METHODS: Scrub typhus cases with confirmed diagnosis throughout the country were included in the analysis. Studies were concentrated in the Chitwan district, the site of a major outbreak in 2016. Additional nation-wide data from 2015 to 2017 available from the government database included to analyse the disease distribution by geographical mapping. RESULTS: From 2015 to 2017, 1239 scrub typhus cases were confirmed with the largest outbreak occurring in 2016 with 831 (67.1%) cases. The case fatality rate was 5.7% in 2015 which declined to 1.1% in 2017. A nationwide outbreak of scrub typhus was declared as the cases were detected in 52 out of the 75 districts of Nepal. Seasonal trend was observed with a peak during August and September. In addition to the human cases, the presence of O. tsutsugamushi was also confirmed in animals (rodents) and chigger mites (Leptotrombidium imphalum) from the outbreak areas of southern Nepal. CONCLUSION: The detection of O. tsutsugamushi in humans, animals, and chigger mites from outbreak locations and wide-spread reports of scrub typhus throughout the country consecutively for 3 years confirms the ongoing transmission of O. tsutsugamushi with a firmly established ecology in Nepal. The country's health system needs to be strengthened for systematic surveillance, early outbreak detection, and immediate actions including treatment and preventive measures.

Health system gaps in cardiovascular disease prevention and management in Nepal.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of deaths and disability in Nepal. Health systems can improve CVD health outcomes even in resource-limited settings by directing efforts to meet critical system gaps. This study aimed to identify Nepal's health systems gaps to prevent and manage CVDs. METHODS: We formed a task force composed of the government and non-government representatives and assessed health system performance across six building blocks: governance, service delivery, human resources, medical products, information system, and financing in terms of equity, access, coverage, efficiency, quality, safety and sustainability. We reviewed 125 national health policies, plans, strategies, guidelines, reports and websites and conducted 52 key informant interviews. We grouped notes from desk review and transcripts' codes into equity, access, coverage, efficiency, quality, safety and sustainability of the health system. RESULTS: National health insurance covers less than 10% of the population; and more than 50% of the health spending is out of pocket. The efficiency of CVDs prevention and management programs in Nepal is affected by the shortage of human resources, weak monitoring and supervision, and inadequate engagement of stakeholders. There are policies and strategies in place to ensure quality of care, however their implementation and supervision is weak. The total budget on health has been increasing over the past five years. However, the funding on CVDs is negligible. CONCLUSION: Governments at the federal, provincial and local levels should prioritize CVDs care and partner with non-government organizations to improve preventive and curative CVDs services.

Factors associated with quality of life among chronic kidney disease patients in Nepal: a cross-sectional study.

BACKGROUND: Chronic kidney disease (CKD) leads to decreased quality of life (QOL) by increasing the risk of death during the progression of its pathogenesis. However, many factors can be improved to support QOL. This study aimed to assess QOL among CKD patients in Nepal and to determine the factors associated with their QOL. METHOD: A cross-sectional study was used for data collection. CKD cases receiving medical attention in the Bir Hospital in Mahaboudh, Kathmandu; Tribhuvan University Teaching Hospital in Maharajgunj, Kathmandu; Sumeru Hospital in Dhapakhel, Lalitpur; and Shahid Dharma Bhakta National Transplant Centre in Bhaktapur between August and October 2019 were invited to participate in the study. A validated questionnaire and the kidney disease quality of life short form (KDQOL-SF™ 1.3) were used to assess QOL. A questionnaire was completed by the researcher in face-to-face interviews. Logistic regression was used to detect the associations between variables at the significance level of α = 0.05. RESULTS: A total of 440 participants were recruited into the study: 56.59% were males, 74.32% were aged between 31 and 70 years, 25.68% were illiterate, and 82.95% were unemployed. The prevalence of good QOL among CKD in the domains of the physical component summary (PCS), mental component summary (MCS), and kidney disease component summary (KDCS) with and without hemodialysis were 53.64, 22.05, 21.28, and 13.19%, respectively. After controlling for all potential confounding factors, eight variables were found to be associated with good QOL in the domain of PCS: age, education, stage of CKD, hemodialysis, transporting oneself to a hospital, health insurance, medical expenses, and perceived lack of difficulty in handling medical expenses. Six variables were associated with good QOL in the domain of MCS after controlling for all potential confounding factors: residence, stage of CKD, transporting oneself to a hospital, health insurance, medical expenses, and perceived lack of difficulty in handling medical expenses. CONCLUSIONS: Public health interventions should be developed and implemented to improve QOL among CKD patients in Nepal by focusing on older female patients who have low education, live in rural areas and no health insurance.

Accessing health services in India: experiences of seasonal migrants returning to Nepal.

BACKGROUND: Migration to India is a common livelihood strategy for poor people in remote Western Nepal. To date, little research has explored the degree and nature of healthcare access among Nepali migrant workers in India. This study explores the experiences of returnee Nepali migrants with regard to accessing healthcare and the perspectives of stakeholders in the government, support organizations, and health providers working with migrant workers in India. METHODS: Six focus group discussions (FGDs) and 12 in-depth interviews with returnee migrants were conducted by trained moderators in six districts in Western Nepal in late 2017. A further 12 stakeholders working in the health and education sector were also interviewed. With the consent of the participants, FGDs and interviews were audio-recorded. They were then transcribed and translated into English and the data were analysed thematically. RESULTS: The interviewed returnee migrants worked in 15 of India's 29 states, most as daily-wage labourers. Most were from among the lowest castes so called-Dalits. Most migrants had had difficulty accessing healthcare services in India. The major barriers to access were the lack of insurance, low wages, not having an Indian identification card tied to individual biometrics so called: Aadhaar card. Other barriers were unsupportive employers, discrimination at healthcare facilities and limited information about the locations of healthcare services. CONCLUSIONS: Nepali migrants experience difficulties in accessing healthcare in India. Partnerships between the Nepali and Indian governments, migrant support organizations and relevant stakeholders such as healthcare providers, government agencies and employers should be strengthened so that this vulnerable population can access the healthcare they are entitled to.

Psychological morbidity in Nepali cross-border migrants in India: a community based cross-sectional study.

BACKGROUND: Since Nepali cross-border migrants can freely enter, work and stay in India, they are largely undocumented. The majority is involved in semi-skilled or unskilled jobs with limited labour rights and social security, a fact which predisposes them to psychological distress. We aimed to assess the prevalence of and factors associated with psychological morbidity among Nepali migrants upon their return from India. METHODS: A community based cross-sectional study was conducted in six districts of Nepal between September 2017 and February 2018. A total of 751 participants who had worked at least six months in India and returned to Nepal were interviewed from 24 randomly selected clusters. The General Health Questionnaire (GHQ)-12 was used to measure the psychological morbidity. Data were analysed using Poisson regression analysis. RESULTS: The majority was younger than 35 years (64.1%), male (96.7%), married (81.8%), had at least a primary education (66.6%), and belonged to Dalit, Janajati and religious minorities (53.7%). The prevalence of psychological morbidity was 13.5% (CI: 11.2-16.1%). Participants aged 45 years and above (adjusted prevalence ratio (aPR) = 2.74), from the Terai (aPR = 3.29), a religious minority (aPR = 3.64), who received no sick leave (aPR = 2.4), with existing health problems (aPR = 2.0) and having difficulty in accessing health care (aPR = 1.88) were more likely than others to exhibit a psychological morbidity. CONCLUSION: This study demonstrated that psychological morbidity was prevalent in the study participants and varied significantly with individual characteristics, work conditions and health. Multifaceted approaches including psychological counselling for returnees and protection of labour and health rights in the workplace are recommended to help reduce psychological morbidity.

Nutrition and food security in Nepal: a narrative review of policies.

In the past few decades, the Nepali government has endorsed several nutritional policies, strategies, and guidelines. Given the lack of a comprehensive review of such policy documents, this review aims to describe the nutrition and food security policies and understand the existing policy gaps in Nepal. Findings from this study can be used to develop policies and programs to address Nepal's current and future nutritional needs. Policies relevant to nutrition and food security were identified by searching government websites and directly approaching relevant government ministries. Thematic analysis was conducted using framework methods under 8 predetermined themes: nutrition intervention, food security, food system, capacity building of human resources, nutrition education, nutrition governance, research, and monitoring and evaluation. The contents of each document reviewed were manually extracted in a spreadsheet stratified by the themes, and the findings were summarized for the respective themes. A total of 30 policy documents were reviewed. Most policies have focused on undernutrition; only a few have addressed overnutrition and diet-related noncommunicable diseases. Food security through a sustainable food system has been considered a key policy area in Nepal. Other areas in the food and nutrition policy landscape are capacity building for human resources, behavior change practices, nutrition governance, monitoring, and evaluation. Policy gaps have been identified in the quality and sustainability of nutrition programs; access to health care services; competent human resources for nutrition; intersectoral coordination and commitment; and support for monitoring, evaluation, and research activities. Most policies have tried to address a wide range of components of food and nutrition security; however, strategies focused on overnutrition and diet-related noncommunicable diseases are lacking. Several gaps are identified in this policy review; the findings can guide the policymakers to address these gaps via further policy development.

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.

The Health Sector Response to the 2015 Earthquake in Nepal.

In April 2015, Nepal experienced an earthquake of a magnitude of 7.6 on the Richter scale that resulted in deaths, morbidities, and infrastructure damage. In the post-earthquake period, 4 different workshops and a national "Lessons Learnt" conference were organized to assess the adequacy of the preparedness and response of the health sector. This article summarizes the main conclusions of these discussions relating to leadership, timely search and rescue, referral operations, medical relief to response activities, awareness campaigns, and support from the national and international levels, and epidemiological surveillance. The earthquake response was channeled through rapid response teams that spanned from the community level to the central level via a cluster coordination approach. Overall, the health sector's response was concluded to be largely satisfactory because it focused not only on emergency medical care, but also on the resumption of basic health services and preventive health care (eg, hygiene, risk communication) equally. Post-disaster disease outbreak did not occur because effective surveillance and outbreak monitoring was one of the priority actions. However, services related to birthing centers, neonatal services, and vaccinations were impeded in some rural areas. Some weaknesses in planning, coordination, and management were also noted. The lessons learned can provide the impetus to strengthen future preparedness and response mechanisms. (Disaster Med Public Health Preparedness. 2018;12:543-547).